86-29 - Laserfiche WebLink

Home Browse Search

i i i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT W 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 V� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 2 q fig , Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the Sart Joaquin Local Health District. / Z3'Z �.-• ._,:;S 74-ry i4 fL�. ,�+ Job Address -6cl 10 JZY A057AX City Lot Size S PM i Owner's Name 7 hIJ �U�Jx'�46C,/A/ ress c290?5 & )45Phone�2 Contractor's Name A 1Q f h icense No. (00"- TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ ��O��T,H,,E�RR 0 DISTANCE TO NEAREST: SEPTIC TANK V 15 SEWER LINES QtIO� DISPOSAL FLDA PROP. LINE FOUNDATION AGRICULTURE WELL BOTHER WELL-42MV&PITS/SUMPS x i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS S ❑ Industrial El Open Bottom Ll Manteca Dia. of Well Excavation / Dia. of Well Casing 9-Domestic/Private K Gravel Pack ❑ Tracy Type of Casing Specifications I ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Q Type of Grout 1 ❑ Irrigation —�-Approx. Depth Q Eastern Surface Seal Installed by Repair Work Done Type'of Pump � _ 1r H.P. T State Work Done Well Destruction ❑ Well Diameter - Sealing Material (top 50'1 ' -f Depth;_ Filler Material (Below 501 x TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION Q DESTRUCTION ❑ jNo septic system permitted if public sewer is! j available within 200 feet.►t M1 Installation will serve: Residence .Commercial_ Other Number of living units: Number of bedrooms r Character of soil to a depth-of-3-feet: Water table depth i SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments j PKG. TREATMENT PLT. ❑ Method of Disposal r y s Distance to nearest: Well Foundation Property Line f E ' i f LEACHING LINE ❑ No. & Length of'lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ' SEEPAGE PITS .❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued,I shel_I employ persons subject to workman's compensa- tion laws of California." j The applicant must call f r a required inspections. Complete drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date r Area Q 1 Pit or Grout Inspection by Date � � Final Inspection b Date Z Additional Comments: ❑ Stk 466-6781 ❑ Lodi 36.9-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i --FEE-- AMOUNT DUE —AMOUNF REMITTED K RECEIVED 8Y-'"—J"`-11ATE�'`""--PERMiT TId.' INFO C + EH 1M4IREV.10183) 1 } Q 4y. EH 14.28 y